Was there a significant difference in the length of ICU stay for the two groups?

Ow Welcome to myCMU | Welcome x Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x * exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid.. low CMU RH Rob Holland 100 1/3 V X Reading list = untitled 1 / 10 |- 125% + INTENSIVE CARE PATIENTS: A CASE-CONTROL STUDY By Li-Yin Chang, RN, MSN, Kai-Wei Katherine Wang, RN, PhD, and Yann-Fen Chao, RN, PhD Background Unplanned extubation commonly occurs in inten- sive care units. Various physical restraints have been used to prevent patients from removing their endotracheal tubes. How- ever, physical restraint not only does not consistently prevent injury but also may be a safety hazard to patients. Objectives To evaluate the effect of physical restraint on unplanned extubation in adult intensive care patients. Methods A total of 100 patients with unplanned extubations and 200 age-, sex-, and diagno is-matched controls with no record of unplanned extubation were included in this case- control study. The 300 participants were selected from a popu- m 2.0 Hours lation of 1455 patients receiving mechanical ventilation during a 21-month period in an adult intensive care unit at a medical center in Taiwan. Data were collected by reviewing medical records and incident reports of unplanned extubation. Notice to CE enrollees: Results The incidence rate of unplanned extubation was 8.7%. A closed-book, multiple-choice examination Factors associated with increased risk for unplanned extubation following this article tests your understanding of included use of physical restraints (increased risk, 3.11 times), the following objectives: 1. Describe the role of physical restraint in nosocomial infection (increased risk, 2.02 times), and a score of unplanned extubation 9 or greater on the Glasgow Coma Scale on admission to the 2. Recognize nursing- and patient-related factors unit (increased risk, 1.98 times). Episodes of unplanned extuba- that increase the risk of extubation. tion also were associated with longer stays in the unit. 3. Review the study presented to evaluate its use- Conclusions An impaired level of consciousness on admission fulness for clinical practice. to the intensive care unit and the presence of nosocomial infection intensify the risk for unplanned extubation, even when physical restraints are used. To minimize the risk of To read this article and take the CE test online, visit unplanned extubation, nurses must establish better standards www.ajcconline.org and click "CE Articles in This for using restraints. (American Journal of Critical Care. 2008; Issue." No CE test fee for AACN members. 17:408-416) O 4 1:51Ow Welcome to myCMU | Welcome x Quiz: Final Article Exam 2 X untitled X G Statistics for Nursing - Elizabeth x exam.docx : AH 316 : Central Me x How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 2 / 10 | 100% + U nplanned extubation is common in intensive care units (ICUs). For most patients, removal of the endotracheal tube and weaning from mechanical ventilation are planned by the medical team. However, some patients deliberately remove the endotracheal tube when they are irritable or uncomfortable, or it may be accidentally removed while a patient is being transported or during a nursing intervention.' The reported incidence rate of unplanned extubation in intensive care patients ranges from 3.4% to 22.5%.' In the past, various restraints have been used to prevent unplanned extubation as well as falls and injuries. Physical restraints include any device, material, or equipment that is attached to a person's body and deliberately prevents the person's free bodily movement. However, the reported incidences of unplanned extubation, even when physical restraints are used, have not changed appreciably in recent years.* Furthermore, several studies have shown that physical restraint not only does not consistently prevent injury, but may increase the possibility of injury and become a safety hazard to patients. Literature Review- investigators's. have suggested that restraining an Risk factors associated with unplanned extuba- unconscious or restless patient might prevent self- tion include both patient- and nursing-related factors. extubation, whereas other researchers" are concerned Risk factors related to patients include restlessness, that use of restraints might cause anxiety and increase agitation, confusion, physical suffering, nosocomial the possibility of unplanned extubation. Nevertheless, infection, and oral (vs nasotracheal) intubation.'s self-extubation occurs despite the use of sedation Risk factors related to nursing include poor fixation and restraints. The reported percentage of the endotracheal tube,' high patient-to-nurse of unplanned extubations initiated The incidence ratios, and the night shift. by restrained patients varies widely, Unplanned extubation of patients who require from 25.6% to 80%. 1515 of unplanned mechanical ventilation can be life-threatening the Sedation, a chemical form of extubation most serious consequences are cardiopulmonary restraint, has been proposed to arrest and death.' The reported reintubation rates decrease the incidence of unplanned ranges from after unplanned extubation are 36% to 57% for the extubation. However, sedation 3.4% to 22.5%. first hour"" and 37% to 57% within 48 hours. $61213 increases the risk for unplanned Replacement of the endotracheal tube often can extubation by prolonging mechanical ventilation lead to hemodynamic and airway complications." and initiating paradoxical agitation.* Physical Unplanned extubation and reintubation are associated restraints remain the first choice when unplanned with longer total duration of mechanical ventilation, extubation is considered a high risk. The inconsis ICU stay, and hospital stay."" Prevention of unplanned tent effect of physical restraints on preventing extubation remains an important issue in critical care. unplanned extubation"." is confusing for clinicians. Problems with unplanned extubation in ICUs Evidence is required to guide the decision about can be handled with or without restraints. Some whether or not to use physical or chemical restraints to decrease unplanned extubation. Purpose. About the Authors Li-Yin Chang is supervisor of the nursing department at The relationship between unplanned extuba- Taichung Veterans General Hospital and is a doctoral tion and physical restraints may differ in various student in the School of Nursing, National Yan settings. We conducted this retrospective study to University, Taipei, Taiwan. Kai-Wei Katherine Wang is an assistant professor in the School of Nursing at National analyze risk factors and explore the influence of Yang-Ming University, Taipei, Taiwan. Yann-Fen Chao is a physical restraints on unplanned extubation. The professor in the College of Nursing at Taipei Medical aims of the study were to (1) identify the factors University, Taipei, Taiwan. associated with increased risk for unplanned extu- Corresponding author: Yann-Fen Chao, RN, Pho, College of bation and (2) determine the risk factors for Nursing, Taipei Medical University, 250 Wu-Xin St, Taipei unplanned extubation in patients with and without City, Taiwan 110 (e-mail: yfchao.tw@yahoo.com.tw). physical restraints. O 5 1:51Ow Welcome to myCMU | Welcome x Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 3 / 10 | - 100% + Methods - Ethical Considerations Design and Sample The study was approved by the ethical review This retrospective, case-controlled study was con- board of the hospital. The standard protocol for ducted in a 42-bed, open-room setting, adult ICU at physical restraint in this unit was (1) an evaluation Taichung Veterans General Hospital, Taichung, Taiwan, of the risk of unplanned extubation and/or fall, Republic of China. The mean number of years that with a physician explaining the necessity of physical nursing staff had worked in the ICU was 4.85 (SD restraint to the patient and the patient's family; (2) 3.73; range, 2-19). The study popu- after obtaining the written medical order and getting Self-extubation lation included all patients who the informed consent form signed by the patient or were admitted and intubated in this the patient's family member, the nurse restraining occurs despite adult ICU during a 21-month period he patient with a proper device; (3) at 2-hour the use of (between October 2003 and July intervals, the nurse removing the physical restraint, 2005). The unplanned extubation performing a massage and range-of-motion exer- sedation and group consisted of 100 patients cises on the restrained joints, and documenting receiving mechanical ventilation observations of the restrained area. restraints. who had an unplanned extubation; the control group consisted of 200 Data Analysis patients receiving mechanical ventilation who had Data were analyzed by using SPSS software (ver- no record of unplanned extubation. sion 12.0 for PC, SPSS Inc, Chicago, Illinois). The In order to increase the statistical power of the major statistical procedures used in this study were study, 2 control patients were selected for each patient x2 test, risk estimation, Mann-Whitney test, t test, who had an unplanned extubation." Case matching receiver-operating-characteristic curve analysis, and was based on each patient's age, sex, diagnosis, and logistic regression. A power analysis based on the dates of hospital stay. The incidence rate of unplanned effect size of the data indicated that the sample size extubation was calculated as follows: [(total number of had a power greater than 90% at the significance level patients with unplanned extubation)/(total number of of .05 for the x2 test, t test, and regression analysis. intubated patients)] x 100. The incidence density of unplanned extubation was calculated as |(total num- Results ber of patients with unplanned extubation)/(total Incidence Rate of Unplanned Extubation number of days of mechanical ventilation)] x 100 In a 21-month period, 126 episodes of unplanned extubation occurred in 1455 patients The unplanned Data Collection receiving mechanical ventilation. The incidence rate Data were collected by review- of unplanned extubation was 8.7% and the inci- extubation group ing medical records and incident dence density of unplanned extubation was 2.07%. had better GCS reports of unplanned extubations Patients in the unplanned extubation group had and completing a structured data diagnoses of pneumonia (37.5%), chronic obstruct scores on admis- collection sheet. Data included ive pulmonary disease (21.5%), substance intoxica patients' demographics, admission tion (14%), and cancer (6%). The mean duration sion, more noso- diagnosis, score on the Acute Physi- of mechanical ventilation before unplanned extuba- comial infections, ological and Chronic Health Evalua tion was 8.6 days (SD, 7.4); 14% of such extubations tion (APACHE) II, total length of occurred on the first day, 54% within the first 7 days, and higher use of ICU/hospital stay, and the follow- and 79% within the first 14 days. The mean score physical restraints. ing data related to the unplanned on the Glasgow Coma Scale (GCS) at the time of extubation: consciousness status, unplanned extubation was 10.6 (SD, 0.8). days of mechanical ventilation, A total of 68 patients were reintubated. The main ventilation parameters, presence of nosocomial reason for reintubation was respiratory distress (63 infection, use of sedation, and use of physical patients). The remaining 5 patients were reintubated restraint. The information on nosocomial infection because of poor cough ability. Among the 68 patients, was offered by the infection control committee and 55 were reintubated within 1 hour. From the 126 was based on the standard of the Centers for Dis patients who had an unplanned extubation, we ease Control and Prevention." In this study, seda- elected the 100 patients who had their first and tives were drugs used to modify behavior, including only unplanned extubation and finished their ICU hypnotic agents (propofol or etomidate) and non- stay during our study period as the unplanned extu- depolarizing muscle relaxants. bation group. A total of 200 patients from the same O 5 1:51Ow Welcome to myCMU | Welcome x Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 4 / 10 - 100% + population matched for age, sex, diagnosis, and dura- group and the control group tion of ICU stay who had no record of unplanned Group extubation were used as the control group. Control Unplanned The characteristics of the unplanned extubation Characteristic n = 200) extubation (n = 100) Statistics P and control groups are listed in Table 1. The mean APACHE II scores were 21.2 (SD, 7.5; range, 3-63) Age, mean (SD), y 65.7 (18.0) $5.2 (19) -0.23 80 for the unplanned extubation group and 22.4 (SD APACHE II score, mean 22.4 (7.3) 21.2 (7.5) -1.36 17 7.3; range, 6-44) for the control group. No signifi- (SD) cant differences were apparent in age, sex, APACHE GCS score, b mean (SD) 9.2 (3.0) 10.1 (2.2) -3.12 .002 II scores, route of intubation, and sedative status Sex, No. (%) of patients 0.01 >.99 between the 2 groups. The unplanned extubation Male 57 (78.5) 9 (79.0) group had better GCS scores on admission (mean Female 13 (21.5) :1 (21.0) [SD], 10.1 [2.2] vs 9.2 [3.0], P = .002), higher rates Route of intubation, 1.06 44 of nosocomial infection (26.0% vs 12.5%, P=.004), No.(%) of patients and higher rates of use of physical restraint (82.0% Oral 186 (93.0) 6 (96.0) vs 54.5%, P <.001 the types of nosocomial infec nasal tion did not differ significantly in frequency between use physical restraint groups unplanned extubation group no. patients also had a longer icu stay than control yes no vs p=".001)." infection .004 among total were phys- ically restrained during their stay. an effort type .29 to identify factors contributing and con- sequences restraints characteristics urinary tract compared who physically pneumonia wa bloodstream age sex sedation apache ii score days intubation route intu- bation or sedative status. better gcs scores on admission higher rates cu length mean .001 d other group. .53 abbreviations: acute physiology chronic health evaluation glasgow coma scale intensive care unit. analyzed by using mann-whitney test b are evaluated admission. risk for subjects never physi- extubation. back- cally ground information was background extu- upper section method if status lower although extuba- groups. however significant differences rate o welcome mycmu x>Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x * exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 5 / 10 - 100% +| characteristics of patients who ura did not have physical restraints score of 9 for an unplanned extubation was 1.98. Physical restraint If physical restraint was used on such a patient, the Used Not used risk of unplanned extubation increased to 6.16 Characteristic (n = 191) (n = 109) Statistics (1.98 x 3.11). If the presence of nosocomial infection Age, mean (SD), y 66.4 (18.2) 64.1 (18.4) t= -1.04 was added, then the risk of unplanned extubation .30 increased to 12.44 (1.98 x 3.11 x 2.02). The cumu- APACHE II score, mean 21.7 (7.2) 22.59 (7.69) t = 1.05 29 lative risk of various combination situations is (SD) illustrated in the Figure. GCS score, mean (SD 10.0 (2.3) 8.6 (3.3) t= -3.61 <.001 sex no. of patients x2="1.93" discussion male incidence rate and factors associated with female increased risk unplanned extubation route intubation .46 the in our study was which higher than that oral by pandey et al lower nasal yeh ven- nosocomial infection tilator-dependent icu enrolled had been receiving mechanical no tilation for hours or more. as a result extubations on first days after were="21.79" not included. extu yes bations happened within this difference between studies may account mean t="-1.29" .19 d reported al. length stay .009 total from icus where nurses less years abbreviations: apache acute physiology chronic health evaluation gcs glas- work experience. all gow coma scale intensive care unit. worked more years. another odds ratio confidence interval explanation high relative is occurred most often when did control group nexperienced caring patients. vs p=".004)." duration before multivariate estimate days. these findings are similar to forward logistic regression pesiri times model used examine intubation. summative occurrence we matched score extubation. variable age diagnosis selected physical restraint hospitalization significant differ- greater. next presence ence variables expected. last i scores groups similar. therefore admission. receiver-operating-characteristic severity conditions effects curve procedure applied best results groups. however cutoff point predicting significantly better sensitivity well rates use specificity entered consciousness restraints devel again summarized table opment also predic overall accuracy tors according he patient o welcome mycmu x>Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 6 / 10 - 100% + Influence of Physical Restraints on Patients and without use of physical restraint Who Had Unplanned Extubation In this study, 82% of unplanned extubations Physical restraint used (n = 191) Unplanned occurred in patients with physical restraints. This find- Control Characteristic extubation (n = 82) (n = 109) Statistics P ing is similar to the results of other studies, " which indicate that use of physical restraint not only is inade- Age, mean (SD), 66.2 (18.7) 66.5 (17.9) t = 0.08 94 quate in preventing unplanned extubation but actually APACHE II score, 21.2 (7.8) 22.0 (6.6) t = 0.69 49 promotes unplanned extubation. Because the GCS mean (SD) scores and rates of nosocomial infection were higher in GCS score, mean (SD) 10.1 (2.2) 9.84 (2.4) t =-0.75 .45 physically restrained subjects (Table 2), it seems likely Route of intubation, X = 0.72 40 that patients who had a higher level of consciousness No. (%) of patients and also had a nosocomial infection had higher rates Oral 79 (96.3) 102 (93.6) of being physically restrained, and the 3 risk factors Nasa 3 (3.7) 7 (6.4) tended to aggregate and led to unplanned extubation. Nosocomial infection, = 5.19 .02 However, GCS scores did not differ significantly No. (%) of patients between the unplanned extubation group and the con- Yes 24 (29.3) 17 (15.6) trol group if the patients were physically restrained, No 58 (70.7) 92 (84.4) and infection rates did not differ significantly between Restraint method, X = 0.01 .9 the unplanned extubation group and the control group No. (%) of patients if the subjects were not physically restrained (Table 3). Wrist 74 (90.2) 98 (89.9) 8 (9.8) 11 (10.1) These results indicate that physically restrained patients Leg with nosocomial infection and patients with better Use of sedation, = 0.48 .49 neurological status who are not physically restrained No. (%) of patients Yes 32 (39.0) 48 (44.0) are most at risk for unplanned extubation. In other No 50 (61.0) 1 (56.0) words, the risk of unplanned extubation can be due No physical restraint used (n = 109) to the use of physical restraints and the presence of Unplanned Control nosocomial infection. extubation (n = 18) Similarly, the risk of unplanned extubation is (n = 91) greater when the patient is not under physical Age, mean (SD) 60.2 (20.3) 64.9 (18.0) t = 0.99 .32 restraint and the patient's GCS score on ICU admis- APACHE II score 20.9 (6.1) 22.9 (7.9) = 1.03 31 sion is 9 or greater. Patients with better GCS scores mean (SD) are more responsive to sensory stimuli. This greater GCS score, mean (SD) 10.3 (2.2) 8.3 (3.4) t = -3.04 .004 responsiveness may explain the increased risk of Route of intubation, Quiz: Final Article Exam 2 X untitled G Statistics for Nursing - Elizabeth x * exam.docx : AH 316 : Central Me x @ How to Take Full Screenshots - C X X C @ File | /home/chronos/u-f7d2627d76fa33b6baf0b992d28674792d012add/MyFiles/Downloads/Final_review_article_2-1%20(2).pdf Q (78 unread) -jackid. ow CMU RH Rob Holland 100 1/3 V X Reading list = untitled 7 / 10 | - 100% + Table 4 Multivariate risk estimate of unplanned extubation in the general groups, b other reason requires careful evaluation, because use Step Factor Exp ( B) 95% Cl for Exp ( B) of physical restraint increases the risk for unplanned extubation by 3.11 times, and the risk increases to Restraint 1.34 <.001 times if a nosocomial infection is also present. constant without physical restraints the risk of unplanned restraint extubation in patient with gcs score or .03 greater on icu admission who has an only than less and no infection. our study patients .04 e.001 had higher ratio confidence interval being restrained abbreviations: ci glasgow coma scale. caution needed when use by forward method wald statistics: accuracy model cox snell r nagelkerk ry hosmer lemeshow test p> .05. s being considered. Initiation of physical restraint In (IP of unplanned extubation /[P of no unplanned extubation ) = -2.143 + on a patient with an infection will increase the risk 0.683(GCS score) + 0.703(infection bation) = e ziaged63 design + jus (restraint). That is, feds tu That is, Odds (unplanned extu- (restraint). In logistic regression of unplanned extubation up to 6.28 times, which is equation, 0 for GCS scores less than 9, without infection, and no physical restraint; much higher than the risk of unplanned extubation 1 for GCS score of 9 or greater, with infection, and with physical restraint. in a patient with only an infection (2.02 times). Limitation of the Study Nosocomial infection 12.44 In this study, data were obtained by reviewing (2.02 the medical charts and incident reports. We assumed Physical that the data were documented accurately and ade- restraint (3.11) No nosocomial quately. Our findings may be biased because of infection (1) -6.16 GCS score 2 9 on selective deposit and selective survival, which are ICU admission common in studies that use existing data. Therefore, (1.98) further investigation is necessary. Nosocomial infection (2.02) 4.00 No physical Conclusions. restraint (1) A GCS score of 9 or greater on ICU admission No nosocomial infection (1) 1.98 increases the risk of unplanned extubation. Patients are more likely to have an unplanned extubation when they are physically restrained. The risk becomes Nosocomial infection higher in the presence of nosocomial infection. To (2.02) 6.28 minimize the risk of unplanned extubation, nurses Physical must assess patients' GCS status and evaluate the restraint (3.11) risk of applying physical restraint. To promote No nosocomial GCS score